TRAVEL VOUCHER (Relocation) SECTION A -- IDENTIFICATION 1. TRAVEL AUTHORIZATION NO. 2. SOCIAL SECURITY NO. 3. NAME (Last) (First) (Middle Initial) 4. AGENCY CODE 5. AGENCY ORIGINATING OFFICE 6. TRAVELER ORIGINATING 7. DATES OF TRAVEL EXPENSES 8. TYPE CLAIM (Indicate one type only) 9. RECLAIM NUMBER OFFICE NUMBER FROM THRU HH = Hsehunting SR = Supp RIT AMOUNT Month Day Year Month Day Year INCLUDED TS = Trans Stn OT = Outside RC = Relo Contr Cont. U.S. RI = RIT Transfer 10. DATE REPORTED AT NEW 11. LEAVE TAKEN 12. OFFICIAL DUTY STATION CITY AND STATE 13. RESIDENT CITY AND STATE (If other than official station) OFFICIAL DUTY STATION Y = Yes N = No Month Day Year 14. TOTAL NIGHTS LODGING 15. NUMBER OF NIGHTS IN APPROVED ACCOMMODATIONS PER THE FIRE SAFETY ACT STANDAR DS SECTION B -- TRAVEL VOUCHER MAILING ADDRESS OPTIONS SECTION D -- CLAIMS 16. SALARY ADDRESS 17. T&A CONTACT POINT 18. SPECIAL ADDRESS 19. TRAVEL EFT ACCOUNT 26. TOTAL SALES PRICE OF FORMER RESIDENCE $ 27. TOTAL PURCHASE PRICE OF NEW RESIDENCE $ 1. (35) 28. EXPENSES CLAIMED BY RELOCATION SERVICES COMPANY (For Type Claim RC Only, Invoice Attached) a. APPRAISED VALUE SALES FEE $ 2. (35) b. AMENDED VALUE SALES FEE $ c. CANCELLATION FEES $ 3. City (20) State (2) Zip Code (9) EXPENSES CLAIMED BY EMPLOYEE SECTION C -- TRANSPORTATION COSTS 29. OUTSIDE CONT. U.S. SUBSISTENCE (Type Claim OT Only) 0.00 20. 21. 22. 23. CAR RENTAL LOCATION METHOD OF VENDOR/ IDENTIFICATION 24. NO. OF AMOUNT AMOUNT DAYS PAYMENT CARRIER NUMBER MILES DAYS CITY ST $ 0.00 $ 0.00 0.00 0.00 0.00 0.00 0.00 If payment was made by traveler, complete Section G on reverse. TOTALS 0 0 $ 0.00 TOTAL OUTSIDE CONT. U.S. SUBSISTENCE $ 0.00 25. AIRLINE ACCOMMODATIONS 30. REAL ESTATE (Paid by Employee) AMOUNT NFC USE Excess fare (Check if applicable) Non-contract (Insert Code) a. SALES EXPENSE (AD-424 Attached) $ SECTION E -- ACCOUNTING CLASSIFICATION b. PURCHASE EXPENSE (AD-424 Attached) 50. AUTHORIZATION ACCOUNTING (Check this block if accounting from travel authorization is to be charged for the total voucher claim.) c. LEASE TERMINATION EXPENSE 51. DISTRIBUTED ACCOUNTING (Check this block and distribute total claim from Section D to 31. PER DIEM the applicable Accounting Classification line.) No. of Days [ 0.00 ] LODGING & IE 0.00 PURPOSE CODE ACCOUNTING CLASSIFICATION PERCENTAGE No. of Travelers [ ] MEALS 0.00 32. MILEAGE % Rate [ ¢] Miles [ 0.00 ] Rate [ ¢] Miles [ ] Rate [ ¢] Miles [ ] Rate [ ¢] Miles [ ] 0.00 33. PARKING, TOLLS, ETC. 0.00 34. PLANE, BUS, TRAIN (Paid by Traveler) 0.00 35. UNACCOMPANIED BAGGAGE 0.00 36. LOCAL TRANSPORTATION 0.00 37. MISCELLANEOUS EXPENSES/ ALLOWANCE 0.00 38. CAR RENTAL 0.00 39. SHIPMENT OF HOUSEHOLD GOODS THESE PERCENTAGES MUST EQUAL 100% Total Weight [ ] 0.00 SECTION F -- CERTIFICATION 40. STORAGE OF HOUSEHOLD GOODS 1ST 30 DAYS FRAUDULENT CLAIM. Falsification of an item in an expense account will result in a forfeiture of the claim (28 USC 2514) and may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both (18 USC 287; i.d. 1001). Total Weight [ ] OVER 30 DAYS CLAIMANT'S RESPONSIBILITIES AND SIGNATURE. I hereby assign to the United States any rights I may have No. Days [ ] against other parties in connection with any reimbursable carrier transportation charges described herein. I have received no 41. TEMPORARY QUARTERS (AD-569 payment for claims shown herein. All travel and reimbursable claims were incurred on official business of the United States attached) Government. All tickets, coupons, promotional items and credits received in connection with travel claimed on this voucher No. of Days [ ] have been accounted for as required by FPMR 101-7 and other regulations. I have reviewed this voucher and certify it to be correct. No. Occupants [ ] 52. CLAIMANT'S SIGNATURE 53. DATE 54. FINAL VOUCHER Month Day Year INDICATOR 42. RELOCATION INCOME TAX Y = Yes N = No (AD-1000 Attached) APPROVING OFFICER'S RESPONSIBILITIES AND SIGNATURE. In approving this voucher, I have determined that: (1) 43. TOTAL CLAIM Reimbursement is claimed for official travel only; (2) Use of rental car, taxicab, or other special conveyance for which reimbursement is claimed (Block 29 thru 42) $ 0.00 is to the Government's advantage; and (3) Long distance phone calls and supplies or equipment purchased are necessary and in the interest of the Government. Note: To approve long distance phone calls, approving officer must have written authorization from Agency Head or his /her 44. TRAVEL ADVANCE AMOUNT designee (31 USC 1348). OUTSTANDING 55. APPROVING OFFICER'S SIGNATURE 56. SOCIAL SECURITY NO. 45. AMT. OF VOUCHER (Block 43) TO BE APPLIED TO OUTSTANDING ADVANCE (Block 44) 57. NAME AND TITLE (Last, First, Middle Initial) (Type or Print) AGENCY CODE 46. AMT. OF VOUCHER (Block 43) TO BE APPLIED TO OUTSTANDING BILL FOR COLLECTION 58. DATE APPROVED 59. PHONE (Area Code and No.) Month Day Year BILL NO. 47 ADDITIONAL ADVANCE AMOUNT 60. CONTACT PERSON 61. PHONE (Area Code and No.) REPAID (Check or Money Order Attached) 48 REMAINING ADVANCE BALANCE Upon completion and approval, submit original voucher to: (Block 43 minus Blocks 45 and 47) 0.00 U.S. Department of Agriculture 49. NET TO TRAVELER National Finance Center (Block 43 minus Blocks 45 and 46) $ 0.00 P.O. Box 60000 AUDITED BY TOTAL DIFFERENCE New Orleans, LA 70160 0.00 FORM AD - 616R (USDA) (Rev. 11/96) This form was electronically produced by National Production Services Staff Exception to SF 1012 approved by GSA 11/20/96 Clear Form SOCIAL SECURITY NO. TRAVELER'S NAME SECTION G -- SCHEDULE OF EXPENSES AND AMOUNTS CLAIMED ITINERARY TOTALS FROM DATE (Month/Day) Transfer these totals to CITY Section D on STATE Voucher Front. TIME TO If additional DATE (Month/Day) days are CITY required, use COUNTY continuation STATE sheet TIME PER DIEM TOTAL NO. DAYS NO. OF DAYS 0.00 LODGING & INCIDENTAL TOTAL LODGING & IE EXPENSES (Receipt Required for Lodging) $ 0.00 TOTAL MEALS MEALS $ 0.00 MILEAGE TOTAL MILES MILES RATE PER MILE ¢ ¢ ¢ ¢ ¢ ¢ ¢ 0.00 TOTAL MILEAGE MILEAGE AMOUNT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 $ 0.00 TOTAL PARKING PARKING, TOLLS, ETC. $ 0.00 TOTAL PLANE, BUS, PLANE, BUS, TRAIN TRAIN (Paid By Traveler) $ 0.00 TOTAL UNACCOMPANIED UNACCOMPANIED BAGGAGE BAGGAGE $ 0.00 LOCAL TOTAL LOCAL TRANSPORTATION TRANSPORTATION NO. TRIPS DAILY EXPENSE $ 0.00 MISCELLANEOUS TOTAL EXPENSES/ MISCELLANEOUS ALLOWANCE $ 0.00 CAR RENTAL TOTAL CAR RENTAL (Paid by Traveler) Receipt and Car Rental Agreement Required RENTAL EXPENSE 0.00 GASOLINE EXPENSE $ SHIPMENT OF HOUSEHOLD GOODS PAID BY TRAVELER (Weight Certificate or Bill of Lading Required) TOTAL WEIGHT OF COMMUTED RATE TOTAL ADDITIONAL ALLOWANCES TOTAL SHIPMENT AMOUNT GOODS SHIPPED X = 0.00 + =$ 0.00 STORAGE OF HOUSEHOLD GOODS NUMBER OF TOTAL ACTUAL COMMUTED CLAIM LESSER AMOUNT AND 1ST 30 DAYS AMOUNT DAYS WEIGHT CHARGES RATE DISTRIBUTE TO APPLICABLE PERIOD $ CLAIMED OF GOODS CHARGES OF STORAGE TEMPORARY STORAGE OVER 30 DAYS AMOUNT $ $ $ $ REMARKS PRIVACY ACT NOTICE. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). The information requested on this form is required under the provisions of 5 USC, Chapter 57 (as amended) and Executive Orders 11609 of July 22, 1971, and 11012 of March 27, 1962, for the purpose of recording travel expenses incurred by the employee and to claim other entitlements and allowances as prescribed in the Federal Travel Regulations (41 CFR 301-304). The information contained in this form will be used by Federal Agency officers and employees who have a need for such information in the performance of their duties. Information will be transferred to appropriate Federal, State, local or foreign agencies, when relevant to civil, criminal, or regulatory investigations or prosecutions or pursuant to a requirement by GSA or such other agency in connection with the hiring or firing, or security clearance, or such other investigations of the performance of official duty in Government service. Failure to provide the information required will result in delay or suspension of the employee's claim for reimbursement.
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